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FORM NO. <br />GWS -31 <br />4/2012 <br />WELL CONSTRUCTION AND TEST REPORT <br />STATE OF COLORADO, OFFICE OF THE STATE ENGINEER <br />1313 Sherman St., Ste 821, Denver, CO 80203 <br />Main 303 866 -3581 Fax 303 866 -3589 www water state co us <br />For Office Use Only <br />1. WELL PERMIT NUMBER: <br />2. WELL OWNER INFORMATION <br />NAME OF WELL OWNER: Patrick Broda <br />MAILING ADDRESS: 14677 Harvest Road <br />CITY: Brighton STATE CO ZIP CODE: 80603 <br />TELEPHONE NUMBER w /area code: 303 - 808 -2500 <br />3. WELL LOCATION AS DRILLED: NW 1/4, SE 1/4, Sec., 30 Twp Fx' N or S, 71 Range 66 ❑ E or W El <br />DISTANCES FROM SEC. LINES. 2550 ft from F— or fx S section line and 2300 ft. from 0 E or ❑W section line. <br />SUBDIVISION: LOT BLOCK , FILING (UNIT) <br />Optional GPS Location: GPS Unit must use the following settings. Format must be UTM, Units Owner's Well Designation. MW -1 <br />must be meters, Datum must be NAD83, Unit must be set to true N, rl Zone 12 or n Zone 13 Easting: <br />STREET ADDRESS AT WELL LOCATION. 1859 N Hwy 85 at WCR 6, Brighton, CO 80603 Northing. <br />4. GROUND SURFACE ELEVATION 4938.94 feet DRILLING METHOD 4" Solid Stem Rotary Auqer <br />DATE COMPLETED 06/17/2010 TOTAL DEPTH 35 feet DEPTH COMPLETED 34 feet <br />5. GEOLOGIC LOG. <br />6. HOLE DIAM in. From ft To ft <br />Depth <br />Type <br />Grain Size <br />Color <br />Water Loc <br />4 0 35 <br />0 -35 ft <br />Sand <br />Sand <br />Lt Brown <br />15 bqs <br />7. PLAIN CASING: <br />OD (in) Kind Wall Size (in) From (ft) To (ft) <br />2 PVC Sch 40 +2.13 -14.0 <br />PERFORATED CASING Screen Slot Size (in): 0.010 <br />2 PVC Sch 40 -14.0 -34.00 <br />8. FILTER PACK: <br />Material Silica <br />Size 10/20 <br />Interval - 12 to -34 <br />9. PACKER PLACEMENT. <br />Type None <br />Depth <br />0. GROUTING RECORD <br />Material Amount Density Interval Placement <br />Bentonih 2 bags -2 to -8 ft Chips <br />Concrete 1 bag 0 to -2 Pad <br />Remarks- <br />11. DISINFECTION. Type None I Amt. Used <br />12. WELL TEST DATA. ❑ Check box if Test Data is submitted on Form Number GWS 39 Supplemental Well Test <br />TESTING METHOD <br />Static Level ft Date/Time measured: Production Rate gpm <br />Pumping Level ft. Date/Time measured Test Length (hrs) <br />Remarks: <br />13. 1 have read the statements made herein and know the contents thereof, and they are true to my knowledge. This document is signed (or <br />name entered if filing online) and certified in accordance with Rule 17.4 of the Water Well Construction Rules, 2 CCR 402 -2. The filing of a <br />document that contains false statements is a violation of section 37- 91- 108(1)(e), C.R.S., and is punishable by fines up to $5000 and /or revocation <br />of the contracting license. If filing online the State Engineer considers entering of licensed contractor name to be compliance with Rule 17.4 <br />Company Name. <br />Dakota Drillinq <br />Phone w /area code, <br />303 - 893 -2811 <br />License Number: <br />234757 <br />Mailing Address- 1380 Umitilla Street, Denver, CO 80204 <br />Sign (or enter name if filing online) <br />Print Name and Title <br />Patrick Broda <br />Date <br />07/10/2012 <br />